Pictures of STIs in RSE – evidence

You might think that the widespread use pictures of STIs in RSE might be based on some kind of evidence of their effectiveness. Nope! Dr Alyssa Lederer, applied behavioural scientist and health education specialist, found the following:

“In 2016 I conducted an experiment with young people enrolled in a large public Midwestern university. Participants watched one of two randomly assigned web-based sexual health programs, one with graphic sexually transmitted infection images and the other without such images but otherwise identical. I then compared the two groups of participants to assess their knowledge, beliefs, and behavioral intentions related to sexually transmitted infections. Overall outcomes were the same, but when I asked participants to provide feedback, more than a quarter of those that saw the graphic images expressed disgust and dismay. These results suggest that presenting such images may prompt stigma – without having any health benefit.” This point about stigma is very important, which I’ll come on to next.

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Fear appeals don’t work either

Meanwhile other studies looking at the effect that scare tactics, also known as ‘fear appeals’, show a similar lack of evidence of effectiveness. Allison Earl and Dolores Albarracín’s study looked into the use of fear appeals. They explicitly talking about the dangers of HIV transmission during a consultation as part of HIV testing. They found that fear appeals during these consultations: “increased perceptions of risk at the immediate follow-up but decreased knowledge and condom use.” This study also found that this decreased condom use following a fear appeal actually strengthened over time (a spiraling effect). Importantly, when interventions instead offered HIV counselling and testing there was an increase of knowledge. Then an increase in condom use and this effect strengthened over time.

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There has been a long history of study of fear appeals or scare tactics and the evidence is contradictory. Some may work in some interventions where individuals are scared enough to want to change their behaviour. IF that change is feasible and accessible to them. However, using a condom is not always easy. Some people find using them easier than others. Earl and Albarracin’s study (and also other studies) suggests that messaging which promotes the gains of condom use, rather than highlighting the losses of condom non-use, are more successful in both the short term and also in the long term.

So studies in the classroom and studies from clinics suggest that scare tactics don’t work. They may even be counterproductive for safer sex practices. Why else might it be a bad idea?

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They Create Stigma

As Dr Alysssa Lederer found that showing images of diseased genitals did not increase the knowledge of students but that it did increase levels of stigma. Study after study shows that stigma has a huge role to play in delaying young people’s attendance at a sexual health clinic, even when they think that they may have symptoms of an STI.

“To promote prompt treatment-seeking, interventions must also address both STI-specific and other forms of social stigma which may limit access to care.” Malta, et al 2007

“Strenuous efforts should be made to overcome the stigma associated with STIs and, by default, GUM services, and to present sexual health services in a way that is seen as inclusive and relevant to a wide range of individuals.” Anne Scoular, et al 2001

“High perceived seriousness about symptoms has both cognitive and emotional components that may function independently to either promote or delay STD-related care seeking.” Cunningham, et all 2005

Which leads to increasing STI transmission

Sexual health education, which seeks to ‘disgust and dismay’ is going to create more stigma around STIs and thus around accessing treatment. (Although there have been significant increases in young people accessing sexual health services due to the expansion of young people’s sexual health services in the noughties). Delaying treatment, or avoiding treatment, increases the risk of transmission and increases the risk of long-term health effects.

In addition, showing pictures of STIs in RSE risks perpetuating other harmful stigmas around sex, which invariably intersect with oppression. Together this sends a message that there are certain ‘kinds of people’ who are at risk of STIs. These messages are homo/biphobic, racist, classist, and definitely sexist. It also creates this problematic and sex negative ‘other’ who has, and might even enjoy, sex. RSE should be trying to address these kinds of messages, not perpetuate them.

So showing these images of disease sends out messages about sexuality and stigma. This is harmful and counterproductive and also inaccurate.

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They are Inaccurate

The majority of cases of STIs don’t have any symptoms. Even where there are symptoms they might be very mild and so not recognisable. They may be confused with other infections or conditions (such as a heavy cold).

The graphic images of STIs which are used in sex education show individuals with symptoms. So in order to be accurate people showing these images should also be showing pictures of people with STIs but no symptoms. We don’t do that. This is because 1) people with asymptomatic STIs are not deemed worthy of photographing by medical professionals. 2) a lot of people find it inappropriate to show young people pictures of genitals without symptoms ie, just genitals.

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Furthermore, the symptomatic pictures of genitals are atypical. That is to say, they show large clusters of warts, or voluminous discharge, or symptoms of tertiary syphilis. These are rare. So they don’t even show the kinds of images of symptoms that people may want to look for when they are checking out their bits in the shower or bath. Eg a small wart, or a blister, drops of blood, a small rash, or an unusual discharge.

Sidenote: I think that we should probably be doing more to teach young people about their genitals. In addition to teaching about diversity (and similarities) of genitals we should also be teaching more about vaginal discharge, papules, in-grown hairs – which are often mistaken for STIs.

… and this sends out an inaccurate learning outcome

So they are not typical images of STI symptoms and thus are not accurate images of STIs. They also have the effect of making STIs seem more serious than they are. The fact is that all STIs are treatable (although yes, gonorrhoea is getting more difficult to treat but is still pretty uncommon). Once treated it’s not common for STIs to have a long term effect for young people.

Even rates of HPV, which is the most common STI in the UK, are coming down dramatically thanks to the HPV vaccine for young people. Rates of genital warts (which are low risk STIs not associated with cervical cancer or any other long term effects, but still feature heavily in graphic images of STIs) have reduced by nearly 80% in young people. We’ve seen that scare tactics don’t work, but we also saw that an overemphasis of how serious STIs are will also increase stigma.

So How Should We Teach About STIs?

Even though we should still teach about STIs, we probably need to tone down some of the messaging. This means we have to a) remove the scare tactics and b) usualise STIs just like we might with any other illness. We should also shift the emphasis to talking about how to negotiate safer sex. Giving people the tools to do this and how to access sexual health services.

Below are some images I made for @BishSexEd on Instagram and Twitter, feel free to download these STI slides and use them in your classes.

You could also try my STI quiz over at BISH which I describe as “a fiendishly difficult quiz but also pretty chilled out and quite real life.” Also there’s my Safer Sex Aces resource or using my Condom Teaching Pack

You could also try the Safer Sex lesson plan over at DO… RSE for Schools,  which I wrote with Alice Hoyle.

There are some more really great ideas about how to teach about STIs in this lovely article by Chella Quint.

The post Should We Show Pictures of STIs in RSE? appeared first on Bish Training - Sex & Relationships Education.

Dear Colleague

It’s World Aids Day on Thursday. Below is a free factsheet, and images to use as a slideshow, from me. Feel free to print out and photocopy. Please do not put this on your own website though. It’s based on my piece at bishUK.com which you can see here

Whilst you’re here, why not check out the reasonably priced and high quality resources and training….

Justin

Factsheet

Click to enlarge

HIV factsheet (pdf)

Images

To save these images to use in a slideshow, simply open each image so they are full size and save to your computer.

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Sex Infections and Safer Sex Leaflet. £7.50 per 50 inc p&p

In my humble opinion, a lesson which is entirely about STIs is a sex negative lesson. Even if it’s a really interactive lesson which involves mixing fluids or trying to work out how many millions of people you have effectively had sex with after having sex with just one person, if it’s just about STIs it’s sex negative and will only have a limited effect.

Giving young people lots of information about STIs, prevalence, names, causes, symptoms, long term effects, damage, tests, treatments won’t work by itself.  It may convince some young people, who weren’t ready for sex yet, that sex generally is a bad idea. However in my experience, young people who are about to or have already started having sex will just switch off. If they are feel ready to have sex, they are going to have sex and they will just ignore information which they think is trying to put them off. They may think ‘I’ll wear a condom’ but they may also think ‘sod it, I’ll just get a chlamydia test and some anti-biotics.’

This is especially true if we use images of diseased genitals (something the kids are now referring to as blue waffle, I wouldn’t image search that if I were you) to try and scare people. In addition to portraying an inaccurate picture of STIs (symptoms are usually unrecognisable or absent) they stigmatise STIs and the people that have them, they portray people with STIs as dirty but also they ‘other’ STIs. They are very very common, sometimes shit happens, we can all get them.

So how I would go about teaching a lesson about STIs is to give a brief overview about the key messages (see the leaflet above), either through a quiz or a brief talk. But then I would introduce an activity which looks at how to make sex safer (see the back of the leaflet above). This makes the information relevant to young people because it reflects the experience of many young people who want to know how to have enjoyable safer sex.

I give young people in small groups a pack of sexy behaviours: sexy things you can do with someone else (or I get them to brainstorm their own sexy behaviours) and I ask them to put them in order of safety. No or low risk, some risk or high risk (I also explain that this in terms of safety from STIs rather than whether you can get in trouble doing it!). They have a conversation with each other about what they see as safe, which in itself is giving them the language confidence to negotiate this in relationships.

We run through what is in the various piles and it’s a good opportunity to clarify things, to provide a little bit more info on STIs. Processing this part of the activity we want the key message to be that penetrative sex can be made safer by using condoms, but also that non-penetrative sex can be super hot but also super safe.

How To Be An Amazing Lover Without Having Sex. £7.50 per 50 inc p&p

Then I ask the young people to sort them out into 4 new piles. 1st base, 2nd base, 3rd base and 4th base. Bases are how far people might go sexually at different stages of a relationship. 1st base might be a first date, 4th base might be when you trust each other loads and know each others middle names. See my bishUK post with a poll about this here

To process this I ask whether there is any link between what was in their risk piles and what is in their base piles. Usually the higher risk activities are also the ones which go on 4th base. So not only are condoms and non-penetrative sex methods of having safer sex, but also the ability to negotiate risks and to communicate within the context of a mutually trusting and intimate relationship.

See? Sex positive is not that scary.

The post Ideas on Sex-Positive Ways to Teach STIs appeared first on Bish Training - Sex & Relationships Education.